BMJ Case Reports: first published as 10.1136/bcr-2013-202734 on 15 January 2014. Downloaded from Images in… Pack of ice: grey scale sign of testicular torsion Suheil Artul,1,2 Basel Fahoum,3 Rami Khoury,1 Yousef Abu Rahmah1 1Department of Radiology, DESCRIPTION EMMS Nazareth Hospital, A 21-year-old man presented to the emergency Nazareth, Israel 2Faculty of Medicine in the department because 2 days prior to presentation, Galilee, Bar-Ilan University, he was with pain and enlargement of right Safed Israel, Nazareth, Israel scrotum. He had no remarkable clinical history. On 3 Department of Urology, physical examination, he was afebrile, oedema and EMMS Nazareth Hospital, redness of right scrotum. Laboratory tests showed Nazareth, Israel leucocitosis up to 14 000 with a left shift. Correspondence to Ultrasound (US) of the right scrotum (figure 1) Dr Suheil Artul, showed enlarged, oedematous and heterogeneous [email protected] testis. At surgery he was found to have torsion of 360°, the testis had some viable tissues and therefore Figure 2 Picture of pack of ice in Antarctica. orchiopexy was performed. This sonographic finding ‘heterogeneous testis’ in our case merits the name of ‘pack of ice’ to its hypoechoic lesions represent infarcted tissue and resemblance to the polar pack of ice (figure 2). the hyperechoic parts represent the viable tissue. fi The US plays an important role in helping differ- Because grey-scale US ndings of torsion are fi ‘ ’ entiate acute epididymo-orchitis from testicular often non-speci c, the sign of pack of ice when torsion, which is a surgical emergency. Both mani- present could be a hallmark of torsion. fest with acute pain and swelling. The role of colour Doppler and power Doppler US in the diagnosis of acute testicular torsion is Learning points well established with sensitivity and specificity of 1 96.8% and 97.9%. On the other hand, grey scale ▸ Heterogeneity of the testes in ultrasound was ultrasound findings vary with the duration and 2 described in the literature as a potential sign of degree of rotation of the spermatic cord, they are torsion and is an add on to the value of the fi non-speci c for testicular torsion and often the diagnosis. testis appear normal if the torsion has just ▸ This sign merits the name of pack of ice. http://casereports.bmj.com/ 3 ‘ occurred. In our case, the heterogeneity pack of ▸ Pack of ice is a sign of testicular torsion. ice’ represents varying degrees of ischaemia: the Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. REFERENCES 1 Waldert M, Klatte T, Schmidbauer J, et al. Color Doppler on 27 September 2021 by guest. Protected copyright. To cite: Artul S, Fahoum B, sonography reliably identifies testicular torsion in boys. Urology Khoury R, et al. BMJ Case 2010;75:1170–4. Rep Published online: 2 Dogra VS, Gottlieb RH, Oka M, et al. Sonography of the scrotum. [please include Day Month Radiology 2003;227:18–36. Year] doi:10.1136/bcr-2013- Figure 1 Grey scale ultrasound of the right scrotum 3 Horstman WG, Middleton WD, Melson GL. Scrotal inflammatory 202734 showing heterogeneity of the scrotum ‘pack of ice’ sign. disease: color Doppler US findings. Radiology 1991;179:55–9. Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow Artul S, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-202734 1.